Faces of Neurosurgery: A Marathon of a Different Kind

hsTyler Martin Schmidt, DO (left)
Neurosurgical Resident at University of Rochester Medical Center
Rochester, NY

Gabrielle Santangelo (right)
Medical Student at University of Rochester Medical Center
Rochester, NY

Dr. Uzma Samadani’s initial reaction was not to operate. Lupe Galeno-Rodreguez was a 15-year-old girl who was already severely limited due to tumors growing on her spinal cord. Her right leg was almost useless; tasks as simple as tying her shoes had become impossible. Lupe had one tumor removed in 2014, but because of her age, follow-up radiation was not offered. But the tumor had come back — and multiplied. Resection of her recurrent tumors would require extensive, high-risk surgery with questionable benefit to the patient.

Dr. Uzma Samadani with her patient, Lupe Galeno-Rodriguez.

Dr. Uzma Samadani with her patient, Lupe Galeno-Rodriguez.

When Dr. Samadani met Lupe and her parents, Oscar Galeno Garcia and Teresa Galeno-Rodriguez, however, she reconsidered. “Looking at a film versus looking at a patient are very different things,” says Dr. Samandani.  Witnessing the suffering of Lupe and her family from the disease, “how could I not offer her surgery,” she contemplated. For Lupe and her parents, the risks of the surgery were equal to the natural course of the disease; they were resolute in moving forward with surgery.

Dr. Samadani began to construct the surgical strategy. Initially, she planned to stage the operation into three separate procedures: two days to remove the tumors (four of the tumors were clustered together, and one was in another area of the spinal cord). The third and final day of surgery would be to fuse Lupe’s spine. At the request of Lupe and her parents, Dr. Samadani modified the plan: a back-to-back two day staged operation. Day one would be dedicated to removing four of the tumors with the spinal fusion occurring the next day. Dr. Samadani would remove the other tumor at a later date.

Day one began at 7:30 AM. Dr. Samadani and her chief resident set out to resect the four clustered tumors in the lower part of the spine. In one region, Lupe had already undergone surgery, and there were significant adhesions and scarring. Dr. Samadani battled to achieve complete removal of the tumor without further damaging Lupe’s nerves. In the sacrum, one tumor had invaded the nerve roots. Dr. Samadani was in uncharted territory. “I had never done a resection in that location before,” Dr. Samadani says.

At 11:00 PM on the first operative day, the four tumors were removed. Lupe’s vital signs were stable. As Dr. Samadani looked at the open wound, she decided to remove the fifth tumor instead of leaving it for a different day.

This tumor, near Lupe’ functional spinal cord, required a delicate approach. After hours of careful microscopic work, the final tumor was out. The patient was taken for a post-operative MRI which confirmed the complete removal of all five tumors. The operative team was tired but satisfied with what they had accomplished for Lupe. Dr. Samadani made her way home to sleep for a few hours before starting the final surgery at 7:30 AM.

Lupe was prone (on her stomach) for 18 hours during the first day of surgery. Of utmost importance was the surgical and anesthesia teams’ collaboration to develop a plan to minimize the risks from the prolonged prone positioning. They monitored Lupe’s intraocular and intracranial pressures, hemoglobin, sodium and fluid balance, and when possible, maintained the patient’s head higher than the heart.

After the second day of surgery, Lupe reported to Dr. Samadani “I can’t see.” Blindness is a dreaded complication of prolonged prone positioning and was one of the complications Dr. Samadani had feared. Fortunately, Lupe’s vision improved to normal within 24 hours.

Immediately postoperatively, Lupe was doing well with minimal pain and no apparent deficits from the prone positioning or the surgery. However, Dr. Samadani was waiting for confirmation that she had achieved what she and her team set out to do: giving Lupe a chance to function as a typical ninth grade girl. Five days after surgery, Lupe got out of bed and used the bathroom. This seemingly mundane milestone was a point of great joy for Dr. Samadani and her team. Such a simple task held promise for Lupe’s recovery. She underwent two weeks of intense inpatient rehabilitation and is now back at school and continues to be active.

Dr. Samadani provides the following advice for young neurosurgeons about cases like Lupe’s. “When you practice neurosurgery, you love cases like this because it is your chance to make a real difference for a person.” She added, “To have them trust you so much and think you can help them and you go and do it, you’re part of a miracle in their lives.”

We salute the work of Dr. Samadani, going the extra mile to create miracle cures for patients like Lupe Galeno-Rodreguez.

Posted in Faces of Neurosurgery, Health, Spine Care | Tagged , , , , , |

Delighted and Proud

debGuest Post from Deborah L. Benzil, MD, FACS, FAANS
Chair, AANS/CNS Communications and Public Relations Committee
Mount Kismo Medical Group
Columbia University Medical Center
Mt Kisco, New York

Having a career as a neurosurgeon is incredibly rewarding. Perhaps even more gratifying is being a part of such a remarkable community. While neurosurgeons represent only one percent of the nation’s physicians, our impact on patients and their loved ones is disproportionately large. In the arena of pain, Neurosurgery Blog’s focus on pain is just one poignant example. For more than a century, neurosurgeons have played a pivotal role in defining and understanding the science of pain. My subspecialty is continuing to contribute to determining the etiology of the leading cause of disabling pain (neck and back pain), developing innovative surgical interventions for these conditions, as well as highly effective surgical treatments for patients with chronic, intractable pain. You would have to have your head under an enormous rock not to know of America’s opioid crisis, but it’s important to point out that the pain crisis is so much more complicated than this cliché allows. The goal of our content during this pain focus has been to explore the nuances of this growing challenge. These include:

pain 2Neurosurgeons have unique and crucial information on this topic that the public needs to know. Furthermore, it’s important to tell all sides of the pain equation and what neurosurgeons experience on the frontlines treating pain, including:

  • Someone who has died or suffered the ravages of opioid addiction;
  • Numerous patients suffering acute or chronic pain from a neurosurgical condition (degenerative spine, brain and spine tumors, infections, peripheral nerve injuries);
  • That narcotics can be essential for patients to achieve the desired quality outcomes in the post-operative setting;
  • Alternative neurosurgical interventions derived through research and innovation are highly efficacious in treating many pain conditions; and
  • Ongoing advocacy and appropriate policy to address the real and complex issues of pain, narcotics and addiction remain critically important.

Neurosurgery Blog will continue to tackle the difficult, but important, issues facing so many patients and their families. Shortly, we will turn our attention from pain into a laser focus month on spine. As the American population continues to age, spine issues will remain as a primary cause of pain and disability, which has a substantial economic impact on the country. As with pain, neurosurgeons are leading the way in addressing this critical topic.

“Of pain you could wish only one thing: that it should stop. Nothing in the world was so bad as physical pain. In the face of pain there are no heroes.”George Orwell

Posted in Guest Post | Tagged , , , , , , , |

The Rush to Limit Opioid Prescribing

winfreeChristopher J. Winfree, MD, FAANS
Department of Neurological Surgery, Columbia University
New York, NY

Ever since the Affordable Care Act (ACA) was passed in 2010, there has been increased attention paid to the use of opioids to treat chronic pain in America. Much of this has been in response to a worsening opioid crisis for patients and non-patients have had access to increasing supply of powerful opioid pain-relieving medications. Ready access to these drugs has enabled patients, and sometimes their family members, to become addicted to these medications. This commonly leads to heroin or synthetic opioid abuse. It is important to note that more patients are dying of opioid overdose than of car accidents, which is a pretty remarkable statistic. At this time, the Trump Administration is considering declaring a national emergency over the developing opioid crisis in America.

op3Given that this crisis is at least partially due to the abundance of readily-available and powerful opioid medications, efforts to reduce the illicit use of opioids as well as their overall availability seem reasonable. Efforts to limit the use of opioids to clinical situations that warrant their use and minimize access to these drugs to patients who do not need them should be applauded. The routine use of prescription drug monitoring programs and opioid contracts for chronic opioid users are examples of laudable efforts to optimize the prescribing of opioids.

Additionally, several states have enacted legislation limiting the prescribing of opioids for acute pain to short periods of time. Arizona, New York, Delaware, and Pennsylvania are examples of states that have a seven-day limit. New Jersey has the strictest law, allowing only a five day supply of opioids. Generally, the limitations do not apply to patients with chronic pain, cancer pain, or in a palliative care program. Pennsylvania allows for longer-term prescribing than seven days if the treating physician documents the medical necessity of the increased opioid prescription and the absence of non-opioid alternatives. Earlier this year, Sens. John McCain (R-Ariz.) and Kirsten Gillibrand (D-N.Y.) coauthored S. 892, the Opioid Addiction Prevention Act, which would restrict postoperative pain medications nationwide to a seven day supply, similar to the state laws already in place. Reps. Phil Roe, MD (R-Tenn.) and Ann Kuster (D-N.H.) have introduced similar legislation (which is more flexible and allows a 10-day supply) by the same name, H.R. 3964, in the House of Representatives. No action has yet been taken on these bills.

In theory, such legislation makes sense if the aim is to limit the supply of new drugs to the general population of opioid-naïve patients presenting to the emergency room with a new, acute pain syndrome. In most cases, a one week supply of opioid medication is sufficient to either adequately treat the patient through the pain episode, or at least treat them until they can follow-up with their outpatient physician for further management.

Unfortunately, this legislation creates an unacceptable hardship for a subset of neurosurgical patients who require opioid medications to treat acute pain that is expected to last longer than one week. Patients who undergo complex spine surgery, such as fusions and scoliosis reconstructions, will almost always require longer-term opioid administration, sometimes lasting several weeks. Head trauma patients who also require management of other painful orthopedic or abdominopelvic trauma often need opioid pain medication lasting longer than one week. Given that all opioid prescriptions require a face-to-face visit with the prescriber, the expectation that a convalescing polytrauma or scoliosis patient will be able to make weekly visits to their physician for an opioid prescription is ridiculous. What will happen in many cases instead, is that patients will not make these appointments and their pain will go undertreated. This will have a detrimental effect on outcomes, as the patient in severe pain will be less likely to mobilize and participate in therapy. A blanket limitation of all opioid prescriptions for acute pain for five to seven days will no doubt hurt many of our neurosurgical patients.

To protect our acute pain patients that require opioids for longer than one week, the AANS, CNS and the AANS/CNS Joint Section on Pain recently sent a letter to Sens. McCain and Gillibrand requesting that the bill allow exceptions for these patients. This should not be a blanket exception weakening the law, but an exception only in specific clinical circumstances that the physician deems appropriate for patients requiring more aggressive opioid management. Such an exemption would be similar to that present in Pennsylvania opioid prescribing law, which allows longer prescriptions than one week when clinically appropriate and sufficiently documented by the treating physician. Our hope is that such an exemption will ensure that our neurosurgical patients who undergo complicated and painful surgical procedures can continue to access vital post-operative pain management strategies.

State and Federal governments have made it clear that restricting opioid prescribing is an essential strategy in reducing the opioid crisis in America. This will hopefully reduce the vast amount of unneeded opioid medications in circulation. As physicians in general, and neurosurgeons specifically, we need to remain active in this legislative process to ensure that our patients continue to have access to the medically-necessary opioids to treat their severe pain, and not be improperly denied access to these crucial medications when most needed.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #painfacts.

Posted in Guest Post, Health, Pain | Tagged , , , , , , , , , , |